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OCS prep > Foot and Ankle > Flashcards

Foot and Ankle Flashcards

1
Q

Tibial external rotation with DF in closed chain resulting in injury with pain at the distal tibia and fibular is associated with what type of injury?

A
  • syndesmotic injury; high ankle sprain
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2
Q

closed chain eversion injury with pain on the medial ankle/foot is associated with what type of injury?

A
  • eversion injury; medial ankle sprain
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3
Q

What is a large difference with care/precautions following a syndesmotic injury (high ankle sprain) compared to a medial or lateral ankle sprain?

A
  • more conservative WB to allow for healing of the syndesmosis
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4
Q

What are the two subgroups/categories/phases conceptually for the CPG for lateral ankle sprains?

A
  • Acute/protected motion phase

- Progressive loading/sensorimotor training phase

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5
Q

What are the characteristics of the acute/protected motion phase?

A

 Significant edema or pain
 w/in ~ 72 hours of injury
 limited weight bearing
 evidence of overt gait deviations

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6
Q

What are the characteristics of the progressive loading/sensorimotor training phase?

A

 Primary concerns of functional instability

 Generally more chronic presentation

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7
Q

What are the two primary ligaments affected by a lateral ankle sprain, and which order are they affected in?

A
  • ATFL first, then CFL
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8
Q

What is the standard mechanism of injury for a lateral ankle sprain?

A

o Ankle/foot in plantar flexed position, followed by hypersupination at forefoot/midfoot

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9
Q

Other than the ATFL and CFL, what structures can be affected by a lateral ankle sprain? (7)

A
  • posterior TFL
  • anterior deltoid ligament
  • lateral subtalar ligament
  • peroneal retinaculum
  • extensor retinaculum
  • peroneal tendons
  • superficial peroneal nerve
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10
Q

What are the main differential dx in the acute phase of lateral ankle sprain? (6)

A 
	Fractures
	Muscle strains
	Cuboid syndrome
	Syndesmosis
	Subtalar joint sprain
	Adjacent joint sprains
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11
Q

What are the main differential dx in the post-acute phase of lateral ankle sprain? (6)

…there are a lot more than 6…but these are the first 6 that showed up in the slide

A 
	Chronic (functional) ankle instability
	Accessory ossicles
	Tarsal coalition
	Impingement (anterolateral or posterior)
	Osteochondral lesions
	Sinus Tarsi Syndrome
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12
Q

What are the Ottawa Ankle Rules for a lateral ankle sprain?

A

Imaging needed if:
- unable to bear weight for more than 4 steps immediately after the injury or in the ED
- pain with palpation of:
• Malleolar zone or midfoot zone
• Posterior edge or tip of either malleolus
• Navicular
• Styloid px of 5th metatarsal

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13
Q

Functional risk factors for lateral ankle sprain are generally related to what two things?

A
  • general movement habits

- ability to correct in the face of a hypersupination load

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14
Q

What 4 functional risk factors for lateral ankle sprain have level I evidence support?

A
  • abnormal gait mechanics
  • impaired postural stability
  • impaired proprioception
  • impaired NM reaction time
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15
Q

What 3 functional risk factors for lateral ankle sprain have Level II evidence support?

A
  • low aerobic fitness
  • deficits in cutaneous sensation
  • deficits in nerve conduction velocity
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16
Q

What 2 functional risk factors for lateral ankle sprain have Level IV evidence support?

A
  • low ankle eversion strength

- impaired balance test performance

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17
Q

What 2 structural risk factors for lateral ankle sprain have Level I support?

A
  • foot and ankle morphology

- specific ankle laxity (increased talar supination; talar tilt)

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18
Q

What 6 structural risk factors for lateral ankle sprain have Level II support?

A
  • limited ankle complex ROM
  • other morphological characteristics
  • general joint laxity
  • limb dominance
  • Female gender
  • specific ankle complex laxity
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19
Q

What 5 extrinsic risk factors for lateral ankle sprain have Level I support?

A
  • Poor environmental conditions/playing surface
  • Court or team-based activity or sport
  • Use of ankle tape and or/brace (reduce)
  • Use of foot orthoses (reduce)
  • Warm up including stretching (reduce)
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20
Q

What 5 extrinsic risk factors for lateral ankle sprain have Level II support?

A
  • Level of competition or intensity
  • Patient sex; effect on severity of injury
  • Preventative efforts and patient education (reduce)
  • Appropriate shoe type to playing conditions (reduce)
  • Slower self-selected running speed
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21
Q

What are 5 outcome measures that are appropriate during eval to assess function for lateral ankle sprain?

A
  • Foot and Ankle Ability Measure (FAAM)
  • LEFS
  • Ankle Joint Functional Assessment Tool (AJFAT)
  • Chronic Ankle Instability Scale (CAIS)
  • Sports Ankle Rating Scale (SARS)
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22
Q

What are 3 appropriate outcome measures designed to identify or grade severity with functional ankle instability? (FAI)

Which ones ID, vs grade severity, or both?

A
  • Ankle Instability Instrument: ID and grade severity
  • Cumberland Ankle Instability Tool: grade severity
  • Functional Ankle Instability Questionnaire: ID
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23
Q

What are the 6 characteristics of a Grade I lateral ankle sprain?

A
  • No loss of function
  • No ligamentous laxity
  • Little or no hemorrhage
  • No point tenderness
  • Decreased total ankle motion of 5 degrees or less
  • Swelling of 0.5 cm or less
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24
Q

What are the 6 characteristics of a Grade II lateral ankle sprain?

A
  • Some loss of function
  • Positive anterior drawer test (ATFL involvement)
  • Negative talar tilt test (no CFL involvement)
  • Hemorrhaging
  • Point tenderness
  • Decreased total ankle motion > than 5* but < 10*
  • Swelling > 0.5 cm but < 2.0 cm
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25
Q

What are the 6 characteristics of a Grade III lateral ankle sprain?

A
  • Near total loss of function
  • Positive anterior drawer and talar tilt tests
  • Hemorrhaging
  • Extreme point tenderness
  • Decreased total ankle motion > 10*
  • Swelling > 2.0 cm
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26
Q

How are Grade IIIA and IIIB lateral ankle sprains defined?

A
  • By radiograph

o Grade IIIA: anterior drawer movement of 3 mm or less
o Grade IIIB: anterior drawer movement of > 3 mm

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27
Q

Describe the execution of an anterior drawer test.

A
  • Medially rotate lower leg, hold foot/ankle in 20* plantar flexion and then pull to look for laxity
  • Or, put pt supine on a table with their knee bent. Palpate talar head, the posteriorly push the tib/fib, feeling for movement
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28
Q

Describe the execution of the talar tilt test

A
  • assess for laxity with rearfoot inversion
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29
Q

What are 3 considerations when measuring ankle DF ROM in open-chain?

A
  • account for the DF axis of rotation being slightly externally rotated; will have to medially rotate the tibia if using cardinal planes
  • Differentiate between gastroc/soleus restrictions, by measuring in prone in knee extension and ~ 45* flexion
  • measure from the plantar surface of the fat pad, not the alignment of the 5th met
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30
Q

What are 4 balance assessments from the lateral ankle CPG?

A
  • Balance Error Scoring System (BESS)
  • Simple Balance Test (SBT)
  • Star excursion balance test
  • Y-balance test
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31
Q

Why do the Simple Balance Test?

A
  • there is a relationship between a positive test result and likelihood for ankle sprains
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32
Q

Young women who have > ___ difference between LEs on the Y balance test are ____ more likely to experience a LE injury on the ____ side

A

 Young women who have > 4 cm gross difference between sides are 2.5x more likely to experience a LE injury on the side that is “shorter”

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33
Q

What is a good activity level test for acute lateral ankle sprain?

What % of difference between sides is concerning and why?

A
  • Lateral hop for distance

- ~20% difference between sides is indicative of prolonged disability

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34
Q

What are 4 hop tests that can be used in the post-acute phase for a lateral ankle sprain to assess for activity/participation?

A
  • figure of 8 hop test
  • square hop test
  • side hop test
  • 6 meter crossover hop test
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35
Q

Is manual therapy appropriate for acute ankle sprain? What grade evidence?

A
  • yes; grade B

- multiple manual techniques are appropriate

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36
Q

What is the CPR for manual therapy for an acute ankle sprain? (4)

A 
	Navicular drop of 5 mm or >
	Symptoms worse:
       •	In standing
       •	In the evening
	Hypomobility of the distal TF joint
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37
Q

What are some appropriate manual techniques noted for lateral ankle sprain? (7)

A
  • active mobilization (muscle energy)
  • oscillatory graded procedures
  • strain-counterstrain
  • manual lymph drainage
  • soft tissue mobilization
  • joint mobs
  • joint manipulations
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38
Q

What is the common goal for manual techniques with lateral ankle sprain?

A
  • improving DF
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39
Q

What are 3 joint manipulations that would be appropriate for lateral ankle sprain?

A
  • long axis traction; bring into DF and quickly pull
  • fibular head manip; posteriorly directed w/ knee in full flx
  • tarsal whip
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40
Q

Are joint manipulations appropriate for acute lateral ankle sprain?

A
  • nah…not really
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41
Q

What are 4 appropriate exercises for acute rehab of lateral ankle sprain?

A
  • AROM
  • seated isometrics
  • hip and trunk exercises
  • arch lifts
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42
Q

What grade evidence supports exercise-based intervention for lateral ankle sprain rehab in the acute phase?

A
  • Grade A. Do it.
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43
Q

In the post-acute phase of lateral ankle sprain recovery, what is the grade of evidence for support of exercise interventions?

A
  • Grade D (conflicting)
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44
Q

Is WB therex recommended for rehab of lateral ankle sprain in the acute phase?

A
  • NWB has support. WB as tolerated, likely, but doesn’t have the same support as NWB in the literature.
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45
Q

Is it ok to reproduce symptoms during WB therex in the post-acute phase of rehab for lateral ankle sprain?

A
  • in general, you want to avoid reproduction of symptoms during and after the therex
46
Q

Does closed-chain therex have support for post-acute phase of rehab for lateral ankle sprain?

A
  • yes, at the impairment level
47
Q

What are appropriate exercises in the post-acute phase of lateral ankle sprain rehab? (4)

A
  • squat, lunge, heel raise progressions
  • trunk progressions
  • arch control progression/integration
  • calf stretch
48
Q

What can be done to avoid plantar fascia stretching when trying to stretch the calf?

A
  • wedge the head of the first met
49
Q

What type of exercise is standard/appropriate for NM re-ed in post-acute lateral ankle sprain rehab?

A
  • ladder drills
50
Q

What is a primary consideration for WB in the acute phase of lateral ankle sprain rehab?

A
  • make sure it’s supported
51
Q

Is early WB in the acute phase of lateral ankle sprain appropriate? What level of evidence?

A
  • yes; supported w/ AD

- Grade A

52
Q

Are bracing/casting appropriate for acute lateral ankle sprain?

A
  • yes
53
Q

Is taping an appropriate intervention for acute lateral ankle sprain?

A
  • yes
54
Q

What are two types of taping for acute lateral ankle sprain?

A
  • open-basket weave

- lateral ankle support

55
Q

What are the recommendations and grades of evidence for acute lateral ankle sprain with the following modalities:

  • Cryotherapy
  • Ultrasound
  • Electrotherapy
  • Short wave diathermy
  • low-level laser
A

o Cryotherapy (A; use!) /therapeutic ultrasound (A; don’t use!)
o Electrotherapy/low-level laser therapy (D)
o Shortwave diathermy (C)

56
Q

Is manual therapy appropriate for heel pain/plantar fasciitis management? What grade of evidence?

A
  • yes

- Grade A

57
Q

What primary impairments are targeted with manual therapy for heel pain/plantar fasciitis?

A
  • joint mobility deficits
  • calf flexibility deficits
  • pain
58
Q

What are often the targets for STM for heel pain or plantar fasciitis? (3)

A
  • gastroc
  • soleus
  • flexor hallicus longus
  • targeted as they are involved
59
Q

What are often the primary targets for joint mobilizations for heel pain/plantar fasciitis? (3)

A
  • talocrural joint mobs
  • sub talar medial/lateral glides (in sidelying)
  • cuboid, navicular, cuneiform manips
60
Q

Is stretching appropriate for heel pain/plantar fasciitis management? What grade evidence?

A
  • yes

- Grade A

61
Q

What are the benefits for stretching for plantar fasciitis/heel pain management? What structures are targeted?

A
  • pain reduction

- gastroc, soleus, plantar fascia

62
Q

When is stretching most beneficial for plantar fasciitis/heel pain?

A
  • first 2-4 weeks
63
Q

What movements create a plantar fascia stretch?

A
  • dorsiflexion with eversion and GT DF
64
Q

How often should plantar fascia stretching occur for management of plantar fasciitis? How long for the holds?

A
  • throughout the day every couple of hours

- for at least 10 seconds

65
Q

Is strengthening or movement training appropriate for heel pain/plantar fasciitis? What grade evidence? What would be the goal?

A
  • it’s fine to do, but there’s no literature behind it
  • Grade F
  • improve strength of musculature that controls pronation and attenuates forces during WB
66
Q

Is open-chain therex appropriate for strengthening for heel pain/plantar fasciitis?

A
  • sure, but doesn’t seem like it’s in favor per medbridge. If able to do WB/closed-chain therex, select that option on the test
67
Q

Is taping appropriate for heel pain/plantar fasciitis?

What grade of evidence?

A
  • yes

- Grade A

68
Q

What two types of taping are appropriate for management of heel pain/plantar fasciitis?

What are their differences?

A
  • anti-pronation (low-dye)
    • stiffer tape
    • impacts pain and function for up to 3 weeks
  • elastic taping to plantar fascia or gastroc
    • only helps with pain reduction
    • gastroc taping only effective for ~1 week

Overall a short-term effect primarily on pain

69
Q

Are foot orthoses appropriate for heel pain/plantar fasciitis? What grade evidence?

A
  • Yes, people should use them

- Grade A

70
Q

Is there a difference between pre-fab or custom orthotics in pt w/ plantar fasciitis?

A
  • nope, not really
71
Q

What is predictive of people who are more likely to benefit from orthoses for heel pain/plantar fasciitis management?

A
  • people who respond positively to anti-pronation taping
72
Q

What are the two primary characteristics of orthotics for heel pain/plantar fasciitis?

A
  • support for medial longitudinal arch

- heel cushion

73
Q

Are the effects for orthotics for heel pain/plantar fasciitis short term, long term, or both?

A
  • both
74
Q

Are night splints appropriate for heel pain/plantar fasciitis? What grade evidence?

A
  • yes

- Grade A

75
Q

How long are night splints typically used to provide a benefit for heel pain/plantar fasciitis?

A
  • 1-3 months

- should be seeing an effect from them within that timeframe

76
Q

What is predictive of people who are likely to benefit from night splints for plantar fasciitis management?

A
  • first step pain in the morning
77
Q

T or F;

Night splints can be a stand-alone intervention for plantar fasciitis.

A
  • F-ish. I mean, they can be, but much more effective as something used in conjunction w/ orthoses, taping, stretching, NSAIDs
78
Q

Is there a difference in efficacy for different types of night splints?

A
  • nope, not really. But most people sleep better with a posterior construction than an anterior one
79
Q

What are the recommendations and grades of evidence for heel pain/plantar fasciitis with the following modalities:

  • Electrotherapy
  • Low level laser
  • Phonophoresis
  • Ultrasound
A
  • Electrotherapy
    • Grade D
    • can be used in conjunction with other things
  • Low level laser
    • Grade C
    • may be used to help pain; no physiological changes noted
  • Phonophoresis
    • Grade D
    • Ketoprofen is commonly used if this is done; can be done
  • Ultrasound
    • Grade C; don’t do it
    • Cannot be recommended for plantar fasciitis/heel pain
80
Q

Are certain footwear recommended for heel pain/plantar fasciitis? What grade of evidence?

A
  • shoe rotation during work week and rocker bottom shoes w/ foot orthoses can be recommended
  • overall Grade D
81
Q

Is dry needling recommended for heel pain/plantar fasciitis? What grade evidence?

A
  • cannot be recommended

- Grade F

82
Q

What type of therex is recommended for heel pain/plantar fasciitis?

A
  • arch raise progressions and integration into WB/dynamic movement
83
Q

Is corticosteroid injection recommended for plantar fasciitis/heel pain management?

A
  • No
  • level I evidence against it’s use due to risk of plantar fascia rupture (~11%)
  • benefit doesn’t outweigh risk
84
Q

Is shockwave therapy appropriate for plantar fasciitis management?

A
  • conflicting evidence…so I’m not going to do it
85
Q

T or F;

Plantar fasciitis is the most common foot condition seen in most clinics

A
  • T

- ~ 15% of all foot complaints in adults are accompanied by plantar fasciitis

86
Q

What are the 3 most commonly reported foot pathologies in athletic populations?

A
  • achilles tendionopathy
  • plantar fasciitis
  • stress fx
87
Q

T or F;

There are pathoanatomical changes in the plantar fascia that accompany plantar fascitis?

A
  • T

- increased plantar fascia thickness is associated with symptoms

88
Q

What is the strongest single contributor to disability with general foot/ankle conditions?

A
  • Pain-related fear of movement
89
Q

What is the typical duration of symptoms with heel pain/plantar fasciitis?

A
  • 13-14 months
90
Q

What % of patients have improvement plantar fasciitis/heel pain symptoms at 1 year follow up?

A
  • 80%
91
Q

What are two Grade B risk factors for development of plantar fasciitis/heel pain?

A
  • limited DF

- high BMI (nonathletic populations)

92
Q

What are risk factors of plantar fasciitis/heel pain? (6)

A
  • limited DF
  • high BMI
  • work related WB activity
  • running
  • high arch type
  • leg length discrepancy
93
Q

What are 5 primary diagnostic indicators of plantar fasciitis? (Grade B)

A
  • first step pain
  • pain with prolonged weight bearing
  • precipitated by an increased volume of weight bearing
  • positive windlass test
  • negative tarsal tunnel test
  • pain with palpation of proximal attachment
94
Q

The windlass test has high specificity and low sensitivity? Or the opposite?

A
  • high specificity and low sensitivity
95
Q

Per the FPI-6, is a more pronated or supinated foot posture associated with chronic heel plantar pain?

A
  • more pronated
96
Q

What are 4 primary differential diagnosis considerations for plantar fasciitis?

A
  • Tarsal tunnel syndrome
  • fat pad atrophy
  • spondyloarthritis
  • plantar fibroma
97
Q

A retrospective study showed that ___% of plantar heel pain patients were diagnosed with fat pad atrophy.

A

15%

98
Q

Plantar heel pain is reported in ___% of patients with spondyloarthritis, with ____% reporting it as the first symptom

A

47% of spondyloarthritis patients had plantar heel pain, with 15% having it as the first symptom

99
Q

What are appropriate outocome measures for pts with plantar heel pain/plantar fasciitis?

A
  • FAAM
  • VAS
  • NRS
  • FPI-6
100
Q

What is mechanically occurring in Tarsal Tunnel Syndrome?

A
  • compression of the posterior tibial nerve by the flexor retinaculum
101
Q

What symptoms are characteristics of Tarsal Tunnel Syndrome?

A
  • burning type pain in the medial arch and ball of the foot
102
Q

Baxter’s nerve entrapment involves which nerve? What is characteristic of it?

A
  • lateral plantar nerve

- burning type pain in weight bearing

103
Q

How much first MTP extension is required for pre-swing phase of gait?

A
  • at least 65*
104
Q

How much eversion ROM should be occurring at loading response? What joints need appropriate mobility to achieve the eversion?

A
  • 4-6* of eversion

- talocalcaneal

105
Q

What muscles primarily help control the rate and extent of pronation?

A
  • tibialis posterior and fibularis longus (peroneus longus)
106
Q

How much DF is required at terminal stance for normal mechanics?

A
  • 10*
107
Q

What musculature restrains tibial progression during ankle DF?

A
  • gastroc
108
Q

Is hamstring tightness associated with heel pain?

A
  • yes; 9x more likely if hamstring tightness
109
Q

How much ROM do you want in a SLR to avoid increased risk for heel pain?

A
  • 75* or >; hamstring length
110
Q

Is education recommended for plantar fasciitis?

A
  • yes; in conjunction with everything else
111
Q

What proximal limitations may be addressed to reduce loading on the plantar fascia?

A
  • reducing hip ER tightness
112
Q

In general, are modalities recommended for plantar fasciitis management?

A
  • no

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